Meidas Health: Congressman Adam Smith on Healthcare Impacts from Shutdown

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3:18Smith of the state of Washington, my home state, join us to talk about the impact of the shutdown on your healthcare and what this means for your family when it comes to accessing needed medical services. Representative Adam Smith, thank you for joining Midas Health. Well, thank you. And I appreciate the chance. Very important topic. Well, Adam, you know, you and I were talking before this episode, and I wanted to give you the floor just to explain to our viewers, our listeners, what the real world impacts are of this shutdown immediately on healthcare benefits and then over time? What are we really talking about here?

3:52What are the stakes? Well, the budget fight, the shutdown fight, has huge stakes. And it's really easy to sort of think of it in two buckets. One is the broader budget, the budget that Trump and his Republican friends in Congress have put in place over the course of the last nine months, which, as Hakeem Jeffries says all the time, has been the most devastating budget to healthcare and our lifetime. The cuts to Medicaid, the cuts to the Affordable Care Act. If you want to broaden healthcare, the cuts to food assistance, which obviously impact the health of people across the country. This budget reflects a set of priorities that doesn't include health.

4:29It is going to put millions of more people off of health insurance. They won't have insurance, and it'll drive up the cost for everybody else. And in place of that, they've done massive tax cuts primarily for the wealthy. They've done a massive increase in the budget for ICE in the Department of Homeland Security, massive increase in the defense budget, all at the expense of health care for the American people. So you've got the budget. And then the second piece of this, which I won't go too far into because it's not directly related to health care, is just the authoritarian way that Donald Trump has run the government.

5:04He has not spent the money as Congress has told him to spend it in a variety of different areas. And in some places, this has hurt health. The cuts that he has made to the CDC and the NIH, the cuts that he has made to scientific research across the country, all unilaterally, and to my mind, illegally. The Constitution states clearly Congress has the power to appropriate money. The president has ignored that and made severe cuts, not to mention, of course, what Secretary Kennedy is doing to our vaccine standards by running the department, the DHS, the way he's running it. So it has been devastating.

5:42And this shutdown fight is an effort to push back. Yes, number one, we want to fund the Affordable Care Act tax credits so that people can continue to afford insurance. But we also want to fundamentally challenge both the Republican budget, which has done such devastating things to health care, as I just described, and to the authoritarian way that Trump is leading, that has undermined public safety in a thousand different ways. It's a really important fight that we're having right now. And then, you know, when I look at the numbers, I say this as a clinician here in Seattle, and I look at the numbers, and the numbers, to me, help explain why when the American public gets polled on this specific issue, and it feels like we have this conversation every 48 years, did we extend the tax credits?

6:31Or, you know, what is the purpose of marketplaces to the Affordable Care Act? And is that something that people support generally? It's the majority of the public, whenever surveyed, that strongly supports the tax credits, the 24 million people that rely on them for durable access to healthcare to keep themselves and their families safe, but also to protect hospitals. Because I think, you know, often what gets missed is if they go underinsured or uninsured. It's still, it's potentially a huge financial cost, not to mention health outcomes burden on communities. I'm curious, what's the public missing here, or what are Republicans trying to hide from the public?

7:14Because this, to me, seems so open and shut. Yeah, two key points, and then I'll get to that third one that you just raised. Washington State's a good example of what you were talking about at first there. We had about 12 % of the population in Washington State that was uninsured prior to the passage of the Affordable Care Act. Between Affordable Care Act, subsidies to it, and improvements to Medicaid, that number has been reduced to 4%. If this Republican budget is allowed to go forward, it will go back up to at least 12. So I don't know what 8 % of 8 million people is off the top of my head, but it's like maybe, you know, 700 ,000 people roughly who will not have health insurance in the state of Washington alone.

7:56So we're talking about millions of people across the country are going to be negatively impacted by this. And then to your second point, so people say, well, that's not me. I'm not on the Affordable Care Act. I've got insurance here. I've got insurance there. Not my problem. But as you know, as a doctor, people still get care. They just get uncompensated care. And every health care provider, particularly ones who are operating on the margins right now, like rural hospitals or community health care clinics, they go under. And now you don't have access to that care. And also they have to charge the people who do have insurance more.

8:30So it impacts absolutely everybody. As far as what the Republicans are pulling over people's highs on this one is a couple issues here. On healthcare specifically, they're saying, look, it's just work requirements. It's just sign up requirements for Medicaid. Another thing they're saying is that the Affordable Care Act tax credits are add-ons that were put on during the pandemic. And some of them were put on during the pandemic, but they were needed before the pandemic, right, for all the reasons that we've stated. But I think the bigger issue right now that Democrats don't address as directly as I think we should is what Republicans are really saying is, look, when the Democrats were in charge, were you happy?

9:14And they point out all the bad things that Democrats have done and in some of our governing challenges in places like Washington state. And I'm not happy, frankly, with the way Democrats have been governing in the Seattle King County area on a wide range of issues. And so it's really sort of whataboutism. And they accuse us of having made all manner of different mistakes all across the board and tried to distract. I've joked that at the end of the day, the Republican message, whenever you attack them on something is, I know you are, but what am I? It's almost that simple. Sometimes they're blaming us for all of this, but many times without any sort of factual connection to it.

9:49They just make the statement and think that if they tell the lie often enough, people will believe it. And sadly, in some cases they have. But on health care, on health care and on the way Trump is running this government, I think we've got a good argument. We just have to keep making it. Obviously, Republicans are going to fight back on their side. But when you look at the impacts that this is going to have, the American people will be with us if we consistently and relentlessly make the case. Adam, I want to get your thoughts on as a follow up. When you look at the state level, which states are most impacted by not opening up the government, not having a thoughtful bipartisan discussion.

10:30They hold the power right now. They could end this. You're standing firm, I think appropriately so. We just had Senator Patty Murray on last week, and I know towards the end of September, she put forward a continuing resolution, Senate Bill 2882 that in addition, it was a CR, but in the proposal, the proposal included reversing cuts to Medicaid and the Big Beautiful Bill, and then also extending the 2021 ECA tax credits, and in effect, just making sure that people had access to care and then otherwise keeping open to the government. They voted across party lines and said no. When you look at the impact, and for all our listeners who may not be living and breathing this.

11:15The states that benefited the most from the 2021 tax credits in just raw absolute numbers, the top 10 states are states that actually went for the president in the 2024 election. When I look at the big, beautiful bill and Medicaid cuts more broadly, there's a fund that supports hospitals, especially rural hospitals, and uncompensated care that sometimes accrues when you care for a Medicaid population. It's an$8 billion fund. Seven of the 10 greatest recipients of that fund that's going to be slashed are states that went for the president. I'm wondering what we're missing on messaging or how we could do a better job of talking about that, because this is a bipartisan issue that frankly impacts the president's voters to some degree, you could say in raw numbers, even more so than, say, the president's detractors.

12:08Yeah, a couple quick points on that, And then the one big thing which you raised, which I could go on forever on, I'll try to make it concise. Yeah, the shutdown, the health care impact is having a much bigger impact. It has an impact in rural areas, which tend to vote for Trump more than not. So, yes, you know, it will cost health care and drive up health care and deny people access to health care in Republican areas vastly more. And the reason the shutdown fight is so important is the Republicans are asking us to vote for their budget. The reason the filibuster exists in the Senate is supposedly to force bipartisanship.

12:46They basically say, no, you can't go full partisan because you can't pass it on your own. You need Democratic votes. And what the Republicans are trying to do is saying, well, screw that. Democrats have to vote for our budget. And if they don't, we're going to blame them for everything. That's what they're trying to do. They're not negotiating with us. The House of Representatives has been out of session for all but a day and a half for over a month now. Mike Johnson is effectively shutting down the United States Congress rather than engaging. And if we don't stand up to that, we're going to wake up and not have a constitutional republic anymore.

13:19We're just going to have a president dictating everything. So it's really crucial. But you ask the question, so if this is having such a negative impact in all of these Republican areas, why do they continue to vote for the Republicans who are taking away their benefits? Because they think the Democrats are worse. And there's not necessarily on health care, but on a range of other issues. Number one, every time a Democrat shows up in one of these areas and tells people that they're voting against their own interests, do we not understand how arrogant that is? You know, how presumptuous it is to say, oh, we know better what we know better than you do what's good for you.

13:57And that type of elitist arrogance has really turned off a lot of people. If you want to show up, people have an argument and say, look, we think health care is important. Fine. But to show up and say, hey, moron, why aren't you voting the way you should be voting? People don't react to that well, unsurprisingly. And second, too much of what Democrats did, in my view, over the course of the last 10 years, and certainly I experienced this in the Seattle-King County area, is we decided, and I use we loosely because I was not part of this, but the broader sort of left side of the coalition decided that there's only one right way to think.

14:33There's only one right way to speak. And there's a whole list of issues where there is only one right position to have. And if you don't think that way, if you don't speak that way, if you don't have that position on the issue, then you are a racist, bigoted, misogynist, ignorant, moron, homophobic, transphobic, awful, terrible, horrible person. And how dare you not say Latinx just to give you one of a thousand different examples? And it pissed people off, pissed me off. OK, I've had to experience that in King County. And I don't have time to get into a whole bunch of stories about that. But I've dealt with that sort of approach.

15:10And even during the pandemic, you know, we were just too condescending in the way that message was. And frequently we turned out to be wrong. OK, I mean, it's bad enough to be condescending and talk down to people. But then when it turns out you're not even right, well, that's going to really upset people. So I think we need to take a step back and say, look, we're not going to treat all 80 million or I forget what the number is of people who voted for Trump and say, you're all awful, horrible. How about we listen to them for a minute? How about we say, yeah, we did some things that probably weren't right, but we're going to fix that.

15:48And really, do you want a society where Donald Trump sends ice into your neighborhood and starts asking you for your papers and locking you up if you don't have them. And that is happening. Okay. It's happening in Chicago right now. It's happening in other places. So we can have that conversation, but we got to start from a place of humility, not from a place of moral superiority. Well said, Adam, really well said. I want to pivot a bit in the remaining time we have with you. And it's similar, but different theme. We're going to stick with healthcare. Lots in the way of, you know, I feel like I'm constantly in my messaging channels dealing with the next headline coming from RFK's HHS.

16:33I've noticed Governors Ferguson, Newsom, others really leading on state-based initiatives. We have the West Coast Health Alliance that I'm proud to be a part of, that you're a part of, that we're all a part of here on the West Coast. I noticed that Governor Newsom just announced an interesting insulin pricing mechanism where California is actually going to partner directly with manufacturers to lower the price of insulin in the state of California than one of the lowest dollar amounts I've seen. It feels fundamentally different, whether it's on drug pricing and what they're doing in California, whether it's the West Coast Health Alliance, state-based action.

17:11It feels like there's substance happening when it comes to communication, meaningful progress on drug pricing versus Maha and what's coming out of HHS, Trump Rx, which seems, again, more marketing than substance, as far as we can tell. I'm wondering how you are thinking about the current state of play. And is it sustainable at the state level to build these coalitions? How should we be thinking about these coalitions? And do you think that we're going to be able to parse through and really cut through the noise here when it's counterposing with the federal podium here? I wonder how we should be thinking about this.

17:52Yeah, three things. First of all, local government stuff you described is an absolute must in the current environment. It's a must in any environment because there are things you can do on the state level to improve people's access to health care and to improve people's health. And I think we should be actively engaged in that. I think it's absolutely required right now that we simply cannot rely on the normal federal government entities like CDC and NIH, given what RFK Jr. is doing to that. So it's really important that Governor Ferguson, Governor Newsom are doing that. It can really have a measurable impact on people's health.

18:27But second, it will never be. Just the nature of so much of our health care system is federal. I mean, I remember way back in 1993 when I believe it or not, I was a state senator and I voted for a universal access to health care system in the state of Washington. But we couldn't get an ERISA waiver from the federal government. So it simply didn't work. There are too many federal regulations that we couldn't get around to make it work. So the federal government plays a big role and we cannot say, well, as long as the states take care of it, health care will be fine. I mean, Medicare, Medicaid, so many aspects of this are on the federal side.

19:01So do all the local stuff, make it happen, push it, but understand that ultimately the federal side is going to matter. And then third, the messaging, I would simply basically repeat what I said. I think it's really important for people opposing President Trump to have a little humility in how we talk about health care, how we talk about energy policy for that matter. I mean, there's just been this desire to be to be self-righteous and morally superior when we're trying to talk about these issues. And look, you know, you're a doctor. I mean, health care is not an exact science. All right. You know, a little humility in terms of what is the right treatment?

19:40What's the right approach? How do we get to a better place? I think could expand that message. But then we also have to forgive me for using it this way. Go for the kill shots, because there are things that RFK Jr. is doing that nobody on God's green earth can defend. I mean, basically now blocking vaccines, blocking the COVID vaccine for so many people that are going to need it, changing the vaccine schedule for children. But I mean, there are certain things he is doing that I think no matter who you are, there's going to be a part of you that's got it. That's just wrong. OK, that is just not the right way to do this, that we should be very aggressive in finding those things.

20:21I think vaccines, 80 % of the country agrees with us and does not agree with R.J. Jr. We should use that over and over and over and over again to say this is why you need Democrats on health care policy right now. Representative Smith, I have to say I've lost your career and your focus on bipartisanship, leading with humility, not talking down to people. I've been a huge fan. I'm delighted and just really privileged that you're joining us at Midas Health. And I just want to thank you for your words today, because I do think we tend, the reaction against expertise is in part driven by exactly some of the trends that you mentioned, which is condescension, talking down, talking, you know, just with statistics, not in real patient stories, and truly trying to understand the other point of view and to play that back and to respond accordingly.

21:18And these are all important reminders, but you're not just reminding us that you're leading right now in DC trying to find a solution. So I just want to say thank you. It doesn't get said enough. Thank you for all you're doing for all of us and for just joining us today at Midas Health. Well, one quick thing, if I could, I'm not really obsessively focused on bipartisanship. I'm focused on solving problems, okay? And sometimes that requires you to reach across the aisle. Sometimes it doesn't. I'm not wedded to any one particular solution. You have to build coalitions that are large enough to succeed in whatever you're doing.

21:53Bipartisanship for bipartisanship's sake. No, I mean, but disagree with people respectfully because odds are some point down the future, you're going to need them. All right. Coalitions ebb and flow and move in one direction or another. I think having a zero sum all or nothing approach just doesn't help you solve the problems we need to solve to govern this country better. So, but I appreciate it. I really appreciate Midas touching your work as well. I remember seeing you back in Seattle back in the day when we'd both be doing interviews down at Como. You have been a tremendous voice on public health for a long time.

22:26And I really, really appreciate your leadership on that. Thanks. Thank you, Adam. Coming from you, that means a lot to me. Thank you so much. And let's make this a habit here, joining Midas Health. Happy to do it anytime.

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